Chapter63 obstetrics and gynaecology (1).pptx

Mudaliar
and
Menon’s
Clinical
Obstetrics
13T H
EDITION

CHAPTER 63
MEDICAL
TERMINATION
OF PREGNANCY
UNIVERSITIES PRESS PVT. LTD

MTP ACT
Passed by Indian parliament in 1971.
Came to force from 1 April 1972.
Except in Jammu and Kashmir where it
came to force from 1 November 1976.
The Act was further amended in December
2002 and the Rules in June 2003.
Under this act, termination of pregnancy can
be done up to 20 weeks of gestation.

LEGAL FRAMEWORK
MTP Act
• Lays down when &
where pregnancies can
be terminated
• Grants the central govt.
power to make rules and
the state govt. power to
frame regulations
MTP Rules
• Lays down who can
terminate the pregnancy,
training requirements,
approval process for
place, etc.

Lays down forms for opinion, maintenance
of records
Custody of forms and reporting of cases
MTP
REGULATIONS

MTP Act:
Indications
 Medical: Continuation of pregnancy
constitutes risk to the life or grave injury to
the physical or mental health of woman
 Eugenic: Substantial risk of physical or
mental abnormalities in the fetus as to
render it seriously handicapped
 Humanitarian: Pregnancy caused by rape
 Contraceptive failure

WHO CAN PERFORM AN
ABORTION
Six months house job in obstetrics and gynecology
A postgraduate qualification in obstetrics and gynecology
Three years of practice in obstetrics or gynecology for
doctors registered before the 1971 MTP Act was passed
A year of practice in obstetrics or gynecology for doctors
registered on or after the date of commencement of the Act

WHERE CAN MTP
BE PERFORMED
 A hospital established or maintained by
the government
 A place approved for the purpose of this
Act by a district-level committee with the
chief medical officer or district health
officer as the chairperson of the said
committee

IMPORTANT ISSUES RELATED
TO MTP
Consent
 Written consent from a guardian for women <18 yrs and
if mentally ill; from woman if >18 yrs of age
Period of gestation
 <12 weeks gestation: Single medical practitioner can
take the decision
 >12 weeks but <20 weeks: Opinion of two registered
medical practitioners is required

PREREQUISITES
FOR MTP
2. Clinical assessment
Clinical assessment for eligibility to undergo
MTP is critical to avoid any complications.
Clinical assessment provides:
Confirmation of pregnancy
Gestational age
Woman’s general health condition
Associated gynecological conditions
Associated medical conditions

PREREQUISITES
FOR MTP
1. Counselling:
Procedure
Risks and complications
The reasons for the termination of
pregnancy must be weighed against the
postabortal complications that are possible
MTP should never be denied to a woman
even if she refuses to use any contraceptive
methods

History
General physical examination for pallor and
edema
Vitals
CVS to rule out cardiac disease
Gynaecological examination
Laboratory investigation
 Hb
 Urine routine
 Blood grouping
Components of
clinical assessment

METHODS OF MTP
FIRST TRIMESTER METHODS SECOND TRIMESTER METHODS
•Menstrual aspiration or regulation
•Dilation and curettage
•Vacuum aspiration
•Use of hygroscopic dilators/
prostaglandins for dilatation of the cervix
•Intraamniotic instillations are not used
anymore as a routine procedure
•Extra-amniotic instillations
•Mifepristone and misoprostol
•Surgical method—hysterotomy

FIRST
TRIMESTER
MTP
Medical
Menstrual aspiration or regulation
Manual vacuum aspiration
Dilatation and curettage
Vacuum aspiration
Hygroscopic dilators/PGs for dilatation of
the cervix

MEDICAL METHOD
Medical abortion with mifepristone (RU 486) followed by
PGE1 analogue—misoprostol is an appropriate method and has
been shown to be safe and effective upto 7 weeks gestation.
Dosage schedule:
Day 1: Tablet mifepristone 200 mg orally in the presence of a
health worker
Day 3: Tablet misoprostol 400 μg orally
Day 15: Visit to the healthcare facility to ensure that the
abortion is complete

MECHANISM OF ACTION
Anti progestin action
Binds to progesterone receptors at endometrium and decidua causing
necrosis and detatchment of placenta
It also softens the cervix and causes mild uterine contraction
Mifepristone sensitises the uterus to the action of prostaglandins
Misoprostol binds to myometrial cells causing strong myometrial
contraction and cervical softening and dilatation resulting in expulsion
of fetus

SIDE
EFFECTS
Nausea
Vomiting
Diarrhea
Headache
Contraindications
Anemia (<8 g%)
CVS/renal disease
Seizure disorders
Uncontrolled HTN

MENSTRUAL
REGULATION/ASPIRATION
Aspiration of endometrial cavity using 5-6 mm karman cannula and
syringe within 6 wks of amenorrhea.
Problems include:
•The woman not being pregnant
•The implanted zygote being missed by the cannula resulting in
continuation of pregnancy
•Failure to recognise an ectopic pregnancy

MANUAL VACUUM ASPIRATION
This procedure provides for termination up to 12 weeks of gestation.
Used for:
Evacuating missed abortion
Molar pregnancy
For removing retained products of conception
CONTRAINDICATIONS
Acute vaginal, cervical or pelvic infection
Suspicion of ectopic pregnancy
Suspicion of perforation

Before procedure
No need for overnight fasting or routine enema
No shaving of perineum; hair could be trimmed if
necessary
Oral analgesic one hour before procedure
A single dose of prophylactic antibiotic can be given
Woman is asked to empty her bladder
Preparation for the procedure
Ensure that the required instruments are available
Assemble the syringe, lock the valve buttons and
withdraw the plunger so that a vacuum is created inside
the syringe
Connect the appropriate cannula; the syringe is now
charged and ready for use
PROCEDURE

The MVA syringe is a 60 cc syringe with a plunger.
The cephalic end consists of a double valve which
helps in producing negative pressure.
It produces a negative pressure of 660 mm of Hg.
It has different cannula from 4 to 12 mm.
Since it is made up of silicone, it can be chemically
sterilised, boiled or autoclaved.

STEPS OF THE PROCEDURE
Lithotomy position under anesthesia on the operation table
Perineum is cleaned and draped
Cervix and vagina are cleaned with povidone-iodine solution
Paracervical block is given
Speculum is inserted and the cervix is visualised
Anterior lip of the cervix is caught with tenaculum forceps and gently pulled
forwards
The charged 60 cc syringe is introduced into the uterine cavity and the valves
are released
Creates negative pressure of 660 mm of Hg

Contents of the uterine cavity can be seen flowing into the syringe and filling
it.
Use a gentle to-and-fro rotatory motion with the cannula.
DO NOT bring the cannula out of the external os.
STEPS OF THE PROCEDURE

Signs of completion of procedure:
Red or pink frothy material passing through the
cannula without tissue
Gritty sensation
Cervix gripping over the cannula
Uterus contracting over the cannula

At the end of the procedure, close the valve,
remove the syringe and cannula and empty the
contents of the syringe into a container and
look for tissues of conception
Clean the vagina and cervix
The woman can be shifted to the cot and
discharged on the same day after four hours

Dilatation and
curettage
This method is now
considered obsolete
since the advent of
vacuum
aspiration/suction
evacuation.

VACCUM
ASPIRATION/
SUCTION
EVACUATION
Quick and efficient
upto 12 weeks of
gestation.
PROCEDURE
Patient is asked to empty the bladder.
Patient in lithotomy position parts cleaned
and draped.
Bimanual examination done to determine
the size of uterus.
Cervix exposed with sims speculum and
anterior lip of cervix held with sponge
forceps or valsellum.
Cervical os is dilated with Hegars dilators
(dilatation 1 mm more than the period of
gestation).

Plastic cannula is introduced into the full depth of uterine cavity
When suction is applied, the cannula is moved over the surface systematically within the uterine cavity to cover
the entire area.
Grating sensation- uterus completely emptied
Uterotonics are given intramuscularly/intravenously if necessary
A gentle curettage may be done if there is still some bleeding.

COMPLICATIONS
Uterine perforation
Sepsis following abortion
Post-abortal tetanus

1. UTERINE
PERFORATIO
N
 This may occur at the time of dilatation,
before evacuation of the uterus or with a
curette, when the evacuation is complete.
 Due to high risk of perforation in a soft
pregnant uterus, the introduction of
uterine sound is usually avoided during
evacuation.
 Depending on the instrument which
causes perforation, there could be an
intraperitoneal bleed necessitating
laparotomy.
 If there is no clinical evidence of shock
(hypotension, tachycardia), management
will depend on the stage of operation
when perforation occurred.

A. If the perforation occurred before evacuation, laparoscopy can be done to
view any bleeding, and suction evacuation can be completed vaginally under
laparoscopic guidance.
At the end of the procedure, if there is no significant bleeding from the
perforation site as observed through the laparoscope, the patient may be kept
under observation and there is no need for a laparotomy.
B. If the perforation has occurred at the end of the procedure and there is no
evidence of an intraperitoneal bleed as assessed by her general condition and
ultrasound, conservative management is recommended.
C. If there is evidence of bleeding laparotomy is required.

2. Sepsis
following
abortion
Septic abortion usually results from criminal
intervention and to a much lesser extent from
legal abortions.
Severe hemorrhage, sepsis, bacterial shock and
acute renal failure are the serious complications.
Sepsis is often caused by a variety of
organisms:
E. coli, Enterococcus, Pseudomonas,
Streptococcus and Proteus are the ones
commonly involved.
Rarely, C. welchii or C. tetani might be the
infecting organisms.
Pregnancy induces alterations in the
maternal immune system, which could be an
important contributory factor in endotoxic
shock following Gram-negative infection in
septic cases.

Alterations in coagulation factors during
pregnancy increase the chances of
disorders which may result in intravascular
coagulation, consumptive coagulopathy
and renal shutdown.
C. welchii infection gives rise to hemolysis
and jaundice.
2. Sepsis
following
abortion

According to the degree of severity, septic abortion is graded as follows:
Grade 1:
Tenderness is confined only to the uterus
The infection being limited to the uterine cavity
Pyrexia of varying degrees and offensive vaginal discharge
The patient’s condition is satisfactory
Vaginal examination may show a partially open or closed cervix with a bulky, tender uterus. The fornices are
free
Grade 2:
The infection has spread beyond the uterus to the parametrium
The patient is more acutely ill
The lower abdomen is slightly rigid, and tenderness is present over the hypogastrium and on either side
Vaginal examination reveals a tender adnexal region and diffuse fullness, with a tender, bulky uterus
Grade 3:
In this group, the patient is very ill with signs of peritonitis—fever, dry tongue, rapid pulse, distended tender
abdomen

TREATMENT
OF SEPTIC
ABORTION
Patients of all three grades should be
hospitalised, and prompt and aggressive
therapy must be instituted.
The aim of treatment is to control infection
by appropriate antibiotic therapy, correction
of electrolyte imbalance and of blood
volume, removal of the infected products
and prevention of further bleeding.

FOR GRADE I CASES
An IV access line is kept open and sufficient fluid is infused to avoid
dehaydration.
Until the sensitivity reports come in, a broad- spectrum antibiotic may
be given orally.
Surgical evacuation of the uterus is undertaken under antibiotic
coverage of 6–8 hours, and the infected products removed by gentle
curettage.

More aggressive treatment is indicated
Intravenous NS/RL should be given
Parenteral broad-spectrum antibiotics are
to be given
Evacuation of the uterus should be done
as soon as possible under antibiotic cover
FOR GRADE II CASES

FOR GRADE III CASES
Patients are at great risk and should be given immediate and aggressive treatment
Prevent vasomotor shock and renal failure
Monitoring the blood pressure, pulse rate, and wherever possible, the central
venous pressure, is essential as also the assessment of the urinary output
Most of these patients will have to be given intravenous infusions to combat shock
and electrolyte imbalance; some may require blood transfusion.
Broad-spectrum antibiotics, covering both aerobes and anaerobes, should be given
intravenously.
High doses should be continued, unless the woman’s clinical response or culture and
sensitivity tests provide an indication for changing the antibiotic regimen after 48–72
hours.
In some of these cases, if the infected products of conception cannot be easily
removed per vaginum, hysterectomy may be suggested.

Currently, the indications for hysterectomy are non-responsiveness to
medical management, traumatic uterine perforation, C. welchi infection
and the development of oliguria.
Early evacuation under antibiotic umbrella is the best option.
Pelvic abscess, if diagnosed, should be drained by colpotomy.
In spite of management, the mortality from septic abortion continues to
be high and accounts for nearly 9% to 16% of maternal deaths due to
direct causes.

CERVICAL
PRIMING
HYGROSCOPIC DILATORS
Laminaria tent made of seaweed
When placed in moist environment such as
cervical canal it will gradually swell to several
times its original size over 6-12 hrs thus dilating
the cervix
Available in three sizes:
Small (3–5 mm)
Medium (6–8 mm)
Large (8–10 mm)
Useful for dilating the cervix for easy
mechanical dilatation and evacuation of uterus

PGs FOR
DILATATION
OF CERVIX
These are slowly replacing the laminaria
tent.
Misoprostol 200–400 µg is used for cervical
priming in MTPs.
Inserted vaginally 3–4 hrs prior to
evacuation.
Helps in easy dilatation and evacuation of
uterus.

SECOND TRIMESTER MTP
Intra-amniotic instillations
Extra-amniotic instillations
Mifepristone and misoprostol
Surgical method—hysterotomy

INTRA-AMNIOTIC INSTILLATIONS
Intra-amniotic instillations are not being used due to associated complications
which may even lead to mortality.
Complications
Death from cardiac failure
Renal shutdown
DIC

EXTRA-AMNIOTIC
INSTILLATIONS
Ethacridine
lactate
(rivanol or
emcredil)
Prostaglandin Normal saline

ETHACRIDINE LACTATE
Acts by producing prostaglandins
from the decidua
It is instilled extraamniotically
through a Foley’s catheter at the rate
of 10 mL for each week of pregnancy
with a maximum limit of 150 mL
The bulb of the catheter is inflated;
the catheter is removed after six hours
 Successful complete abortion takes
place in a high percentage of cases
within 36 hours
Whenever there is delay, syntocinon
drugs can hasten the process
MIFEPRISTONE AND
MISOPROSTOL
Mifepristone 200 mg followed by
misoprostol after 36 to 48 hours
Misoprostol is given orally in doses
of 400 μg every 4 hourly for five
doses or 800 μg vaginally followed
by 400 μg orally for four doses

HYSTEROTOMY
Hysterotomy may have to be resorted to
when all other methods of second trimester
abortion fail.
Tubal sterilisation can be done
simultaneously.
Hysterotomy may have to be resorted to
when all other methods of second trimester
abortion fail.
Very often, the pregnancy following
hysterotomy should be delivered by cesarean
section.

MEDICOLEGAL ISSUES
RELATED TO MTP
Medicolegal issues can arise following the MTP in the following areas:
Failure to obtain consent
Failure of termination and continuation of pregnancy
Retained products of conception
Damage to the viscera
Failure to administer anti-D immunoglobulin following MTP in an Rh-negative
mother
Sex determination tests and disclosure of the sex of the fetus prior to MTP are
punishable
Death of the woman following MTP

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